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APPLICATION FOR PERMIT r- SAN JOAQUIN LOCAL HEALTH DISTRICT © �LL 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 h}0 \zR c� `-s to Ig PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) 7N'\t5 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ff Job Address 1 ��CS2'\tS�Ld,, City Lot Size PM Owner's Name �� J�i� l�j{�cd ,c:a� r_ Address Phone Contractor a 51Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A ONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing \ ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Ty of Casing Specifications (yt ❑ Public ❑ Other elta Depth Grout Seal Type of Grout 1 ❑ Irrigation ---Approx. Dept .`❑ Eastern Surface 5 I Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Wel{ Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is availabie within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's comliensa- tion laws of California." he cant mus call for II required i spections. Complete drawing on reverse side. r Signed Title: iir►no�� Date: f� ARTMENT USE ONLY .Application Accepted by cia..A,4 Date v "J Area Pit or Grout Inspection by Date Final Inspection by Date C� Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant- Return all copies toL Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED I AS RECEIVED By DATE rr /P�E,RggqMIT NO. EH 13-24{REV.i/e5} EH 1 �_V0 428 je